Pass Point- Fundamentals
A parent of a 9-year-old child who is scheduled to have surgery expresses concern about the potential for a postoperative infection. Which information would be most important for the nurse to tell the parent?
"All visitors should wash their hands before they leave or enter the room."
The nurse is precepting a graduate nurse and preparing to give infant immunizations. The preceptor asks the graduate, "Infant injections should only be given in which muscle?" What is the best response by the graduate nurse?
"vastus lateralis"
A child is to receive dexamethasone intravenously at the ordered dosage of 7.6 mg. The drug concentration in the vial is 4 mg/ml. The nurse should administer?
1.9
A woman employed full-time wants to request a leave of absence to care for her father who is being treated for colon cancer 300 miles (480 km) away. What should the nurse advise the client to do first?
Contact her employee resources department about policies guiding leaves of absence.
A nurse notes that a client's I.V. insertion site is red, swollen, and warm to the touch. Which action should the nurse take first?
Discontinue the I.V. infusion.
The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response?
Explain that this information cannot be disclosed without the client's permission.
The nurse is caring for a client scheduled for surgery who, on the morning of the scheduled operation, states a desire to cancel it. What would be the best response by the nurse?
Explore reasons why the client wishes to cancel the surgery, clarify concerns, and reinforce that there can be a change.
A client of Anglo-Saxon descent (e.g., Anglo-American or English Canadian) reports to the primary healthcare facility with symptoms of fever, cough, and running nose. While interviewing the client, which points should the nurse keep in mind?
Maintain eye contact while talking.
A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. What should the nurse do in order to obtain admission information from the client?
Obtain a trained medical interpreter.
What should the nurse do to ensure safety for a hospitalized blind client?
Orient the client to the room environment.
The nurse is required initially to restrain all four of a client's extremities. For what reason would the nurse anticipate the need to add a full-length restraint blanket?
The client is at risk for injury from fighting the restraints.
What short-term goal for a client hospitalized with a stress related disorder is most realistic?
The client will write a list of strengths and needs.
Professional values of nursing
The nurse is demonstrating integrity which is defined as acting in accordance with an appropriate code of ethics and accepted standards of practice. Seeking to remedy errors made by self or others is an example of integrity. Altruism is a concern for the welfare and being of others. Social justice is upholding moral, legal, and humanistic principles. Human dignity is respect for the inherent worth and uniqueness of individuals and populations.
Sodium polystyrene sulfonate is prescribed for a client following crush injury. Which finding indicates the drug has been effective?
The serum potassium is 4.0 mEq/L (4.0 mmol/L).
Which of the following is an important consideration when the nurse is providing culturally competent care in a community clinic?
asking about cultural beliefs related to health, illness, treatments, and dietary practices
For a hospitalized client, the physician orders morphine, 4 mg I.V., every 2 hours as needed for pain. However, the client refuses to take injections. Which nursing action is most appropriate?
calling the physician to request an oral pain medication
The nurse notes serous discharge when an abdominal dressing is changed. The nurse would document this drainage as which of the following?
clear, watery, yellow-tinged drainage
When planning pain control for a client with terminal gastric cancer, a nurse should consider that
clients with terminal cancer may develop tolerance to opioids.
A client who has been recently diagnosed with acquired immunodeficiency syndrome (AIDS) inquires about hospice services. What should the nurse tell the client about these services? Hospice services are appropriate:
for clients with an inevitable death within weeks to months.
A nurse is assessing a client for the risk of falls. The nurse should obtain
gait and balance information.
A community health nurse is planning to address the physical needs of older adults living in their homes. What primary areas would be included in this discussion?
importance of exercise, balanced nutrition, mobility and safety needs
A nurse must assess skin turgor in an older adult client. What would the nurse keep in mind when assessing this client?
inelastic skin turgor is a normal part of aging
In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional values?
integrity
A nurse assesses the client's pulse as weak and thready in both lower extremities. How would the nurse best document this finding?
pulse amplitude +1 bilateral lower extremities
A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?
signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous
A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?
sodium Na+
A nurse reports to the hospital occupational health nurse (OHN) that the nurse was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when test results will show positive or negative for HIV infection for the nurse. Which of the following is the most appropriate response by the OHN?
Accurate results will be obtained by testing at 3 months and again at 6 months."
A client diagnosed with schizophrenia for the last 2 years tells the nurse who has brought the morning medications, "That's not my pill! My pill is blue, not green." What should the nurse tell the client?
"I'll go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color."
A client has been using Chinese herbs and acupuncture to maintain health. What is the best response by the nurse when asked if this practice could be continued during recuperation from a long illness?
"Let's discuss your desire to integrate these practices with the physician and advocate on your behalf."
Students in a health class are discussing birth control and prevention of sexually transmitted disease. The school nurse would know that teaching has been effective if the students state which of the following?
"Responsible sex involves using condoms and spermicides for protection and birth control."
While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which of the following statements is the most therapeutic response by the nurse?
"You are concerned that the client is receiving too much narcotic medication?"
Which of the following situations is an indication of the benefit of self-awareness in professional nursing practice by a nurse? Select all that apply.
-Examines own biases and is open to new ideas -Understands the meaning of cultural diversity
A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today but had to cancel the appointment when the child became ill. Which action should the nurse take?
Arrange for the pump to be refilled in the hospital.
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
Stop the feedings and check for residual volume.
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next?
Promptly assess the client for potential perforation.
A client has been admitted with type 2 diabetes mellitus and asks to have the local medicine man come and help decide what traditional aboriginal medicines could help. What are the appropriate nursing interventions based on this client's request?
Suggest that the client inform and discuss with the interprofessional team how traditional therapies could be integrated into the plan of care.
A client who has been prescribed chemotherapy wants to take herbal treatments instead. What should the nurse tell the client?
Tell me about your concerns with chemotherapy."
The nurse is trying to establish a trusting relationship with a client experiencing pain. When the client asks for pain medication, the nurse notes that it is not time to give the medication. What is the best action by the nurse to facilitate a trusting relationship?
Tell the client when the medication is due and return promptly at that time.
Which sentence correctly describes the prone position?
The body is facedown.
A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse?
The nurse should listen attentively and provide realistic verbal reassurance.
A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?
The nurse uses a rocking motion while helping the client to stand.
The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which of the following is a correct component in the nursing plan of care?
documenting the situation and providing support for the victim
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site has which appearance?
evidence of a bleb
An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first?
intravenous fluid hydration
A nurse has attended an in-service workshop to address the phenomenon of ageism in the healthcare system. Which practice is indicative of ageism?
speaking to older adults in a way one would with clients who have mild cognitive deficits
When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply.
-that the client understood -the information that there was voluntary consent on the client's part -that the client has full awareness of the potential complications -that there was adequate disclosure of information
20s Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?
Temperature of 102° F (38.9°C)
A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply.
-Have two nurses check the blood type and identity. -Initiate an IV with normal saline. -Take baseline vital signs.
A child has a nasogastric (NG) tube inserted by the nurse to administer a continuous feeding. Which actions should the nurse take before starting the NG feeding on the child? Select all that apply.
-Verify the physician's order. -Check placement of the NG tube. -Assess for bowel sounds.
Which action performed by a nurse will increase the risk of liability? Select all that apply.
-assisting a client on ordered bed rest to walk to the toilet -asking unlicensed assistive personnel to assess a client's wound -providing information to a caller about a client's diagnosis and treatment
A cardiologist prescribes digoxin 125 mcg by mouth every morning for a client diagnosed with heart failure. The pharmacy dispenses tablets that contain 0.25 mg each. How many tablet(s) would the nurse administer in each dose? Record your answer using one decimal place. (For example: 6.2)
0.5
